Elucidating Axillary Soft Tissue Involvement in Breast Cancer: Unveiling Metastatic Mechanisms and Therapeutic Perspectives

This perspective focuses on axillary soft tissue (AXT) involvement in breast cancer, revealing diverse pathological entities beyond traditional axillary lymph node metastasis. AXT involvement is linked to increased risks of distant metastasis and locoregional failure, emphasizing its significance in predicting breast cancer outcomes. We posit that AXT involvement could signify a retrograde metastatic event stemming from reactivated circulating tumor cells navigating towards the axillary soft tissue guided by chemokines. Therefore, AXT disease warrants aggressive systemic therapy. Axillary radiation therapy could be a potentially preferable alternative to axillary lymph node dissection. Routine reporting of axillary soft tissue involvement is crucial for accurate treatment planning.

Evaluating Radar Reflector Localisation in Targeted Axillary Dissection in Patients Undergoing Neoadjuvant Systemic Therapy for Node-Positive Early Breast Cancer: A Systematic Review and Pooled Analysis

SAVI SCOUT® or radar reflector localisation (RRL) has proven accurate in localising non-palpable breast and axillary lesions, with minimal interference with MRI. Targeted axillary dissection (TAD), combining marked lymph node biopsy (MLNB) and sentinel lymph node biopsy (SLNB), is becoming a standard post-neoadjuvant systemic therapy (NST) for node-positive early breast cancer. Compared to SLNB alone, TAD reduces the false negative rate (FNR) to below 6%, enabling safer axillary surgery de-escalation. This systematic review evaluates RRL's performance during TAD, assessing localisation and retrieval rates, the concordance between MLNB and SLNB, and the pathological complete response (pCR) in clinically node-positive patients post-NST. Four studies (252 TAD procedures) met the inclusion criteria, with a 99.6% (95% confidence [CI]: 98.9-100) successful localisation rate, 100% retrieval rate, and 81% (95% CI: 76-86) concordance rate between SLNB and MLNB. The average duration from RRL deployment to surgery was 52 days (range:1-202). pCR was observed in 42% (95% CI: 36-48) of cases, with no significant migration or complications reported. Omitting MLNB or SLNB would have under-staged the axilla in 9.7% or 3.4% (p = 0.03) of cases, respectively, underscoring the importance of incorporating MLNB in axillary staging post-NST in initially node-positive patients in line with the updated National Comprehensive Cancer Network (NCCN) guidelines. These findings underscore the excellent efficacy of RRL in TAD for NST-treated patients with positive nodes, aiding in accurate axillary pCR identification and the safe omission of axillary dissection in strong responders.

Reevaluating Axillary Lymph Node Dissection in Total Mastectomy for Low Axillary Burden Breast Cancer: Insights from a Meta-Analysis including the SINODAR-ONE Trial

Complete axillary lymph node dissection (cALND) was previously the standard of care for breast cancer (BC) patients with axillary node disease or macro-metastases found via sentinel lymph node biopsy (SLNB). However, due to significant morbidity, contemporary management now considers a more selective approach, influenced by studies like ACOSOG Z0011. This trial showed that cALND could be omitted without compromising local control or survival in patients with low axillary nodal disease burden undergoing breast-conserving therapy, radiotherapy, and systemic therapy. The relevance of this approach for women with low axillary nodal burden undergoing total mastectomy (TM) remained unclear. A PubMed search up to September 2023 identified 147 relevant studies, with 6 meeting the inclusion criteria, involving 4184 patients with BC and low-volume axillary disease (1-3 positive lymph nodes) undergoing TM. Postmastectomy radiotherapy receipt was similar in both groups. After a mean 7.2-year follow-up, both the pooled results and the meta-analysis revealed no significant differences in overall survival. The combined analysis of the published studies, including the subgroup analysis of the SINODAR-One trial, indicates no survival advantage for cALND over SLNB in T1-T2 breast cancer patients with 1-3 positive sentinel lymph nodes (pN1) undergoing mastectomy. This suggests that, following a multidisciplinary evaluation, cALND can be safely omitted. However, the impact of other patient, tumor, and treatment factors on survival requires consideration and therefore further prospective trials are needed for conclusive validation.

Unlocking the Power of the Homing Phenomenon: Why Breast Conserving Surgery Outshines Mastectomy in Overall Survival

Breast cancer stands as the most frequently diagnosed malignancy in women, holding a prominent position among the leading causes of cancer-related fatalities on a global scale. Despite significant advances in treatment modalities, approximately 20% of patients experience relapses after the first 5 years of postdiagnosis surveillance. While initial investigations from the 1970s indicated comparable survival rates between breast-conserving surgery (BCS) coupled with radiation therapy and mastectomy, recent research suggests that, within the context of modern systemic and radiation therapy, BCS followed by radiation may offer an improved overall survival benefit. Nevertheless, extended follow-up studies have unveiled a notable increase in the risk of locoregional recurrence associated with breast conserving therapy in contrast to mastectomy. This article introduces a novel hypothesis rooted in the biological phenomenon of homing to elucidate this intriguing clinical observation. We postulate that a breast homing mechanism of reactivated circulating and disseminated tumor cells mediated by chemotaxis involving at least the CXCR4-SDF-1 axis may provide a biological rationale for this clinical phenomenon.

Cryogenic Media in Biomedical Applications: Current Advances, Challenges, and Future Perspectives

This paper explores the crucial role of cryogenic mediums in driving breakthroughs within the biomedical sector. The objective was to investigate, critically discuss, and present the current knowledge and state-of-the-art practices, along with the challenges and perspectives of the most common applications. Through an extensive literature review, this work aims to supplement existing research, offering a comprehensive and up-to-date understanding of the subject. Biomedical research involving cryogenic mediums is advancing on multiple fronts, including the development of advanced medical technologies, clinical treatments for life-threatening conditions, high-quality biospecimen preservation, and antimicrobial interventions in industrial food processing. These advances open new horizons and present cutting-edge opportunities for research and the medical community. While the current body of evidence showcases the impressive impact of cryogenic mediums, such as nitrogen, helium, argon, and oxygen, on revolutionary developments, reaching definitive conclusions on their efficiency and safety remains challenging due to process complexity and research scarcity with a moderate certainty of evidence. Knowledge gaps further underline the need for additional studies to facilitate cryogenic research in developing innovative technological processes in biomedicine. These advancements have the potential to reshape the modern world and significantly enhance the quality of life for people worldwide.

The Evolving Role of Cryosurgery in Breast Cancer Management: A Comprehensive Review

Breast cancer is the most commonly diagnosed type of cancer, accounting for approximately one in eight cancer diagnoses worldwide. In 2020, there were approximately 2.3 million new cases of breast cancer globally, resulting in around 685,000 deaths. Consequently, there is an ongoing need to develop innovative therapeutic approaches that can improve both clinical outcomes and patient quality of life. The use of ultra-low cryogenic temperatures, facilitated by cryogenic media such as liquid nitrogen, has revolutionized the biomedical field and opened up new possibilities for advanced clinical treatments, including cryosurgery. Cryosurgery has demonstrated its feasibility as a minimally invasive technique for destroying breast tumors and eliciting a significant antitumor immune response in the host. This feature sets cryosurgery apart from other ablative techniques. It has been shown to be well tolerated and effective, offering several advantages such as simplicity, the avoidance of general anesthesia, minimal pain, low morbidity, short recovery time, cost-effectiveness, and notably, improved aesthetic outcomes. The reviewed studies indicate that cryosurgery holds promise in the management of early-stage breast cancer and metastatic disease, especially in triple-negative and Her2-positive molecular subtypes in conjunction with checkpoint inhibitors and anti-Her2 antibodies, respectively. Furthermore, the effectiveness of cryosurgery in the management of ductal carcinoma in situ should be investigated as an alternative modality to surgery or surveillance. The minimally invasive nature of cryosurgery has the potential to significantly enhance the quality of life for patients.

Omitting Sentinel Lymph Node Biopsy after Neoadjuvant Systemic Therapy for Clinically Node Negative HER2 Positive and Triple Negative Breast Cancer: A Pooled Analysis

Recent advances in systemic treatment for breast cancer have been underpinned by recognising and exploiting subtype-specific vulnerabilities to achieve higher rates of pathologic complete response (pCR) after neo-adjuvant systemic therapy (NAST). This down-staging of disease has permitted safe surgical de-escalation in patients who respond well. Triple-negative (TNBC) or HER2-positive breast cancer is most likely to achieve complete radiological response (rCR) and pCR after NAST. Hence, for selected patients, particularly those who are clinically node-negative (cN0) at diagnosis, the probability of disease in the sentinel node after NAST could be low enough to justify omitting axillary surgery. The aim of this pooled analysis was to determine the rate of sentinel node positivity (ypN+) in patients with TNBC or HER2-positive breast cancer who were initially cN0, achieving rCR and/or pCR in the breast after NAST. MedLine was searched using appropriate search terms. Five studies (N = 3834) were included in the pooled analysis, yielding a pooled ypN+ rate of 2.16% (95% CI: 1.70-2.63). This is significantly lower than the acceptable false negative rate of sentinel lymph node biopsy (SLNB) and supports consideration of omission of SLNB in this subset of patients.

Pathologic Response of Associated Ductal Carcinoma In Situ to Neoadjuvant Systemic Therapy: A Systematic Review

Contrary to traditional assumptions, recent evidence suggests that neoadjuvant systemic therapy (NST) given for invasive breast cancer may eradicate co-existent ductal carcinoma in-situ (DCIS), which may facilitate de-escalation of breast resections. The aim of this systematic review was to assess the eradication rate of DCIS by NST given for invasive breast cancer. Searches were performed in MEDLINE using appropriate search terms. Six studies (N = 659) in which pathological data were available regarding the presence of DCIS prior to neoadjuvant chemotherapy (NACT) were identified. Only one study investigating the impact of neoadjuvant endocrine therapy (NET) met the search criteria. After pooled analysis, post-NACT pathology showed no residual DCIS in 40.5% of patients (267/659; 95% CI: 36.8-44.3). There was no significant difference in DCIS eradication rate between triple negative breast cancer (TNBC) and HER2-positive disease (45% vs. 46% respectively). NET achieved eradication of DCIS in 15% of patients (9/59). Importantly, residual widespread micro-calcifications after NST did not necessarily indicate residual disease. In view of the results of the pooled analysis, the presence of extensive DCIS prior to NST should not mandate mastectomy and de-escalation to breast conserving surgery (BCS) should be considered in patients identified by contrast enhanced magnetic resonance imaging (CE-MRI).

Accurate Screening for Early-Stage Breast Cancer by Detection and Profiling of Circulating Tumor Cells

BACKGROUND

The early detection of breast cancer (BrC) is associated with improved survival. We describe a blood-based breast cancer detection test based on functional enrichment of breast-adenocarcinoma-associated circulating tumor cells (BrAD-CTCs) and their identification via multiplexed fluorescence immunocytochemistry (ICC) profiling for GCDFP15, GATA3, EpCAM, PanCK, and CD45 status.

METHODS

The ability of the test to differentiate BrC cases (N = 548) from healthy women (N = 9632) was evaluated in a case-control clinical study. The ability of the test to differentiate BrC cases from those with benign breast conditions was evaluated in a prospective clinical study of women (N = 141) suspected of BrC.

RESULTS

The test accurately detects BrAD-CTCs in breast cancers, irrespective of age, ethnicity, disease stage, grade, or hormone receptor status. Analytical validation established the high accuracy and reliability of the test under intended use conditions. The test detects and differentiates BrC cases from healthy women with 100% specificity and 92.07% overall sensitivity in a case-control study. In a prospective clinical study, the test shows 93.1% specificity and 94.64% overall sensitivity in differentiating breast cancer cases (N = 112) from benign breast conditions (N = 29).

CONCLUSION

The findings reported in this manuscript support the clinical potential of this test for blood-based BrC detection.

Breast Tumour Kinase (Brk/PTK6) Contributes to Breast Tumour Xenograft Growth and Modulates Chemotherapeutic Responses In Vitro

Breast tumour kinase (Brk/PTK6) is overexpressed in up to 86% of breast cancers and is associated with poorer patient outcomes. It is considered a potential therapeutic target in breast cancer, even though the full spectrum of its kinase activity is not known. This study investigated the role of the kinase domain in promoting tumour growth and its potential in sensitising triple negative breast cancer cells to standard of care chemotherapy. Triple negative human xenograft models revealed that both kinase-inactive and wild-type Brk promoted xenograft growth. Suppression of Brk activity in cells subsequently co-treated with the chemotherapy agents doxorubicin or paclitaxel resulted in an increased cell sensitivity to these agents. In triple negative breast cancer cell lines, the inhibition of Brk kinase activity augmented the effects of doxorubicin or paclitaxel. High expression of the alternatively spliced isoform, ALT-PTK6, resulted in improved patient outcomes. Our study is the first to show a role for kinase-inactive Brk in human breast tumour xenograft growth; therefore, it is unlikely that kinase inhibition of Brk, in isolation, would halt tumour growth in vivo. Breast cancer cell responses to chemotherapy in vitro were kinase-dependent, indicating that treatment with kinase inhibitors could be a fruitful avenue for combinatorial treatment. Of particular prognostic value is the ratio of ALT-PTK6:Brk expression in predicating patient outcomes.

The Role of Community Pharmacists in Addressing Medication-related Issues for Breast Cancer Patients Receiving Adjuvant Endocrine Therapy

Breast cancer is the most common cancer in women globally. To prevent relapse and prolong disease-free survival, adjuvant endocrine treatment such as selective oestrogen receptor modulators and aromatase inhibitors are being used. However, such oestrogen-blocking agents can cause serious adverse events. Community pharmacists are ideally positioned to ensure that such adverse events are addressed promptly and competently through their comprehensive knowledge of medicines. To identify the skills and training required to improve community pharmacists' communication in breast cancer settings regarding adjuvant endocrine treatments and to propose a conceptual framework for setting up such breast cancer service, we reviewed the literature using PubMed and performed a brief survey of eight community pharmacists using semi-structured interview method. To improve pharmacists' competencies in breast cancer settings, a clear framework for the proposed service on the national level is required. In addition to communication skills training programmes and problem-solving competences, reviewing the pharmacy pre-registration training curriculum and creating appropriate platforms that monitor medications in breast cancer patients are advocated.

Sensitivity, Specificity and the Diagnostic Accuracy of PET/CT for Axillary Staging in Patients With Stage I-III Cancer: A Systematic Review of The Literature

BACKGROUND/AIM

Axillary lymph node (ALN) status plays a key role in the staging of breast cancer. Positron Emission Tomography/Computed Tomography (PET/CT) using 18-Fluorodeoxyglucose (¹⁸FDG) can visualise ALN metastasis. However, its utility compared to current methods is unclear. We systematically reviewed the role of ¹⁸FDG PET/CT in breast cancer staging.

MATERIALS AND METHODS

PubMed, Ovid and Cochrane were searched systematically up until August 2020. Included papers had true positive (TP), false positive (FP), true negative (TN) and false negative (FN) rates, sensitivity, specificity, accuracy, positive (PPV) and negative predictive value (NPV).

RESULTS

Nine studies (n=1486) were included, showing: i) sensitivity=52.2%, ii) specificity=91.6%, iii) PPV=77.8%, iv) NPV=77.2, and v) accuracy=77.3%.

CONCLUSION

¹⁸FDG-PET/CT has a low sensitivity but high specificity for ALN disease. Therefore, ultrasound-guided biopsy could be considered in a positive CT/PET. Modest accuracy prohibits the use of ¹⁸FDG-PET/CT alone in axillary staging. Prospective research using standardised protocols and quantitative cut-off points is warranted.

Unilateral axillary adenopathy following COVID-19 vaccination: a multimodality pictorial illustration and review of current guidelines

We present a multimodality pictorial review of axillary lymphadenopathy in patients recently vaccinated against COVID-19. As the mass vaccination programme continues to be rolled out worldwide in an effort to combat the pandemic, it is important that radiologists consider recent COVID-19 vaccination in the differential diagnosis of unilateral axillary lymphadenopathy and are aware of typical appearances across all imaging methods. We review current guidelines on the management of unilateral axillary lymphadenopathy in the context of recent COVID-19 vaccination.

Is Autologous Fat Grafting an Oncologically Safe Procedure following Breast Conserving Surgery for Breast Cancer? A Comprehensive Review

BACKGROUND

Autologous fat grafting (AFG) is a recognized surgical procedure to correct deformities following breast conservation surgery (BCS) for breast cancer. However, there are concerns about the oncological safety of this technique. In this study we have reviewed the current literature to assess whether AFG adversely influences the oncological outcome after BCS for breast cancer.

METHODS

We have searched the medical literature using the Embase and PubMed search engines from conception until May 2019 to identify all relevant studies of patients who underwent AFG after BCS. Meta-analysis and meta-regression methodologies were used to calculate the overall relative risk (RR) of loco-regional recurrence (LRR) rates for case-control and case series studies (with historical controls) respectively.

RESULTS

We have identified 26 eligible studies with a total of 1640 patients who had undergone fat transfer after lumpectomy for breast cancer. The meta-analysis of 11 studies revealed an overall RR for LRR of 0.82 [95% confidence interval (CI):0.14-1.66]. The meta-regression of case series revealed an overall incidence of LRR of 1.85% compared with 2.53% for historical controls.

CONCLUSIONS

Our study lends further support to the notion that fat transfer after lumpectomy for breast cancer does not seem to increase the risk of LRR. However further prospective research is required in order to confirm this.

De-escalation of Axillary Surgery in the Neoadjuvant Chemotherapy (NACT) Setting for Breast Cancer: Is it Oncologically Safe?

BACKGROUND/AIM

The treatment of breast cancer has progressed considerably over the years, with a significant de-escalation from radical mastectomies to the current paradigm of breast conserving surgery (BCS) and neoadjuvant chemotherapy (NACT). We aimed to appraise the literature regarding the feasibility of de-escalation of treatment of axillary disease in the context of NACT.

MATERIALS AND METHODS

We appraised studies and guidelines published regarding this topic and discussed them in this mini-review.

RESULTS AND CONCLUSION

The SNB following NACT is oncologically safe in patients with clinically node negative disease and in patients with biopsy proven axillary node involvement at presentation provided that the dual technique is used and the clipped pathological node is harvested.

Stratification Using hTERT and Stem Cell Markers Confers a Good Prognosis in Invasive Breast Cancer

BACKGROUND/AIM

In this study, we aimed to investigate the prognostic role of a previously identified panel of 10 stem cell markers stratified against the catalytic subunit of telomerase (hTERT) in human breast cancer.

MATERIALS AND METHODS

The mRNA copy numbers of these genes were determined using real time quantitative PCR in 124 breast cancer tissues and adjacent non-cancerous tissues. Relations between mRNA levels and survival were analysed using Kaplan-Meier plots and Cox regression analysis.

RESULTS

Five genes (BMI1, NES, POU5F1, ALDH1A2 and CDKN1A) correlated with survival when stratified with hTERT and predicted overall (Wilcoxon: p=0.004; Cox: p=0.006) and disease-free (Wilcoxon: p<0.000; Cox: p=0.000) survival.

CONCLUSION

This panel of genes stratified by hTERT could open new avenues for the development of new prognostic tools, as well as for the identification of new research directions regarding breast oncogenesis.

Reflector-guided Localization of Non-palpable Breast Lesions: The First Reported European Evaluation of the SAVI SCOUT® System

BACKGROUND

Wire-guided localization (WGL) has been the mainstay for localizing non-palpable breast lesions before excision. Due to its limitations, various wireless alternatives have been developed. In this prospective study, we evaluate the role of radiation-free wireless localization using the SAVI SCOUT® localization at a European centre.

PATIENTS AND METHODS

This technique was evaluated in a prospective cohort of 20 patients. The evaluation focused on clinical and pathological parameters in addition to patient and physician acceptance.

RESULTS

SAVI SCOUT reflectors (n=23) were deployed to localize 22 occult breast lesions and one axillary lymph node in 20 patients. The mean deployment duration was 5.6 min, with a mean distance from the lesion of 0.6 mm. The migration rate was 0% and the mean identification and retrieval time was 25.1 min. In patients undergoing therapeutic excision for malignancy (n=17), only one (5.9%) required reoperation for positive surgical margins. Radiologists and surgeons rated the technique as better than WGL and patient satisfaction was high.

CONCLUSION

Our study demonstrates that wireless localization using SAVI SCOUT® is an effective and time-efficient alternative to WGL with excellent physician and patient acceptance.

Savi Scout® Radar Localisation of Non-palpable Breast Lesions: Systematic Review and Pooled Analysis of 842 Cases

BACKGROUND/AIM

With the increase in detection of non-palpable breast lesions through screening, wire-guided localisation (WGL) has long been the favoured method for preoperative localisation. However, this technique comes with several limitations. New methods have been developed, including several non-radioactive, wireless options. We aimed to assess the effectiveness of Savi Scout® localisation (SSL) through this pooled analysis and systematic review.

MATERIALS AND METHODS

A number of databases were searched for records reporting data on localisation and retrieval of SSL reflectors, as well as re-excision rate. We included our own data from 20 patients (22 reflectors) at our institution.

RESULTS

A total of 842 reflectors were inserted across eleven studies and our own data. Pooled analysis revealed an overall successful deployment rate of 99.64% and a successful retrieval rate of 99.64% using SSL. A statistically significant difference in re-excision rate was found in a smaller pooled analysis conducted across four studies comparing SSL and WGL (12.9% and 21.1% respectively, p<0.01).

CONCLUSION

The Savi Scout® localisation system is a safe and effective alternative to WGL. It facilitates flexible scheduling by decoupling radiology and surgery interventions and may reduce the need for re-excision procedures for positive surgical margins.

Mammographic Breast Density and Urbanization: Interactions with BMI, Environmental, Lifestyle, and Other Patient Factors

Mammographic breast density (MBD) is an important imaging biomarker of breast cancer risk, but it has been suggested that increased MBD is not a genuine finding once corrected for age and body mass index (BMI). This study examined the association of various factors, including both residing in and working in the urban setting, with MBD. Questionnaires were completed by 1144 women attending for mammography at the London Breast Institute in 2012–2013. Breast density was assessed with an automated volumetric breast density measurement system (Volpara) and compared with subjective radiologist assessment. Multivariable linear regression was used to model the relationship between MBD and residence in the urban setting as well as working in the urban setting, adjusting for both age and BMI and other menstrual, reproductive, and lifestyle factors. Urban residence was significantly associated with an increasing percent of MBD, but this association became non-significant when adjusted for age and BMI. This was not the case for women who were both residents in the urban setting and still working. Our results suggest that the association between urban women and increased MBD can be partially explained by their lower BMI, but for women still working, there appear to be other contributing factors.

Wireless Breast Localization Using Radio-frequency Identification Tags: The First Reported European Experience in Breast Cancer

BACKGROUND/AIM

Wire-guided localisation (WGL) has been the mainstay for localisation of clinically occult breast lesions before excision. However, it has restrictive scheduling requirements, and causes patient discomfort. This has prompted the development of various wireless alternatives. In this prospective study we shall evaluate the role of radiation-free wireless localisation using a radiofrequency identification (RFID) tag and a hand-held reader (LOCalizer™) in the management of occult breast lesions.

PATIENTS AND METHODS

This technique was evaluated in a prospective cohort of 10 patients. The evaluation focused on: i) successful deployment, ii) identification and retrieval, iii) the status of surgical margins and need for re-operation, iv) resected specimen weight, v) marker migration rates (>5mm), and vi) acceptance by patients, radiologists and surgeons.

RESULTS

RFID tags (n=11) were deployed under ultrasound guidance pre-operatively to localise occult breast lesions in 10 patients. The mean time for deployment of the RFID tag was 5.4 min (range=2-20). The mean distance from the lesion was 0.45 mm (range=0-3). The mean duration for retrieval was 10.2 min (range=6-20). Mean specimen weight was 19.6 g for malignant lesions (range=4.5-42). All tags were identified, and none had migrated. There were no positive margins, re-operations, nor complications. Patient feedback was highly positive. Both radiologists and surgeons rated the LOCalizer™ technique as better than WGL.

CONCLUSION

Our study demonstrates that wireless localisation using RFID is an effective and time-efficient alternative to WGL, with low margin positivity and re-operation rates, and high patient, radiologist and surgeon acceptance.

Evolving Role of Magseed in Wireless Localization of Breast Lesions: Systematic Review and Pooled Analysis of 1,559 Procedures

BACKGROUND/AIM

Wire-guided localisation (WGL) remains the most widely used technique for the localisation of non-palpable breast lesions; however, recent technological advances have resulted in non-wire, non-radioactive alternatives, such as magnetic seeds (Magseeds). The aim of this pooled analysis was to determine whether Magseeds are an effective tool for localising non-palpable breast lesions.

MATERIALS AND METHODS

Various databases were searched for publications which reported data on the localisation and placement rates of Magseed. Data on re-excision rates under use of Magseed and WGL were also collected.

RESULTS

Sixteen studies, spanning the insertion of 1,559 Magseeds, were analysed. The pooled analysis showed a successful placement rate of 94.42% and a successful localisation rate of 99.86%. Four studies were analysed in a separate pooled analysis and showed no statistically significant difference between re-excision rates using Magseeds and WGL.

CONCLUSION

The use of Magseeds is an effective, non-inferior alternative to WGL that overcomes many of the limitations of the latter.

Locoregional therapy of the primary tumour in de novo stage IV breast cancer in 216 066 patients: A meta-analysis

Patients presenting with de novo stage IV metastatic breast cancer have a complex disease which is normally treated with palliative intent and systemic therapy. However, there is mounting evidence that resection of the primary tumour and/or localised radiotherapy (locoregional therapy; LRT) could be associated with overall survival improvements. We aimed to conduct a meta-analysis to inform decision making. Using the PubMed, Cochrane and Ovid SP databases, a literature review and meta-analysis were conducted to assess the effect of LRT on overall survival. Studies were analysed for the impact of LRT on survival. All forms of LRT resulted in a significant 31.8% reduction in mortality (N = 42; HR = 0.6823 (95% CI 0.6365; 0.7314)). Surgical resection resulted in a significant 36.2% reduction in mortality (N = 37; HR = 0.6379 (95% CI 0.5974; 0.6811)). The prospective trials reported a 19.23% reduction in mortality which was not statistically significant (N = 3, HR = 0.8077 (95% CI 0.5704; 1.1438). 216 066 patients were included. This is the largest meta-analysis regarding this question to date. Our meta-analysis shows that LRT of the primary tumour seems to improve overall survival in de novo stage IV disease. Therefore, this therapeutic option should be considered in selected patients after a careful multidisciplinary discussion.

Abstract P4-13-09: Oncoplastic breast conserving surgery (OBCS): A meta-analysis of real-world data

Background: The role of oncoplastic breast conserving surgery (OBCS) is that of a middle ground between standard breast conserving surgery (SBCS) and mastectomy - it allows adequate resection margins of tumours unsuitable for traditional breast conserving surgery whilst allowing for a better cosmetic outcome and a reduced morbidity rate when compared to a traditional mastectomy. However, due to this being a relatively new type of procedure, there is limited evidence on its oncological safety, which is the ultimate goal of any breast cancer surgery.

Methods: This study aims to compare oncological safety of OBCS with SBCS and mastectomy by examining the relative risk of cancer recurrence and re-operation rates through meta-analysis. Literature search of Pubmed and Web of Science databases was conducted looking for studies up until February 2019. Meta-Analysis was performed using R Statistical Software (www.r-project.org).

Results: Initial finding of 645 studies was narrowed down to a pool of 19 studies including 18,163 patients. For the primary outcome measure of recurrence there was found to be no significant difference between the OBCS and SBCS or mastectomy (RR 0.861; 95% CI 0.640-1.160; p&lt;0.296). The secondary outcome measure of re-operation was initially found to be significant in favour of OBCS (RR 0.64; 95% CI 0.46-0.89; p&lt;0.01), however after adjustment for publication bias this was attenuated to an insignificant difference between the two study groups (RR 0.86; 95% CI 0.56-1.31; p&gt;0.05).

Conclusions: For both recurrence of cancer and re-operation rate, there was not found to be a significant difference between OBCS and more traditional techniques. This would suggest that OBCS is of comparable oncological safety to more established operations and a useful option in suitable patients.

Citation Format: Sebastian Kosasih, Salim Tayeh, Kefah Mokbel, Abdul Kasem. Oncoplastic breast conserving surgery (OBCS): A meta-analysis of real-world data [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-13-09.

Abstract P6-14-07: The evolving role of pre-pectoral acellular dermal matrix -assisted approach in implant-based immediate breast reconstruction following conservative mastectomy: A prospective observational study

Background: The recent development of acellular dermal matrix (ADM) devices has enhanced implant-based breast reconstruction (IBR) surgery following nipple-sparing mastectomy (NSM) for therapeutic and risk-reducing purposes leading to improved aesthetics. In the traditional sub-pectoral approach, coverage of the implant is provided by the pectoral muscles superiorly and the ADM inferiorly. The need to eliminate breast animation, reduce post-operative dysfunctional pain and the risk of capsular contracture, have stimulated surgeons to investigate the feasibility of placing the implant over the pectoralis major muscle with complete coverage with ADM thus introducing a novel pre-pectoral approach. The aim of this study was to evaluate the short clinical outcomes and patients’ satisfaction after NSM combined with ADM-assisted immediate IBR.

Materials and Methods: Thirty consecutive patients underwent 40 pre-pectoral ADM-assisted IBR following NSM (61% therapeutic and 39% risk-reducing). A peri-areolar incision was used in all cases. A fixed volume microtextured (Mentor) or nanotextured (Sebbin) implant was used in 32 single stage procedures (80%) and a microtextured tissue expander was used in 2-stage reconstruction in 8(20%). A fenestrated ADM (SurgiMend) was used to provide full coverage of the implant. A drain and prophylactic antibiotics and anti-thromboembolism measures were used in all cases. All patients were followed up regularly in the outpatient department and were invited to complete a bespoke satisfaction questionnaire.

Results: A total of 9 (22.5%) patients had prior radiotherapy (RT) or post-mastectomy RT (PMRT). Seventeen patients (56.7%) received adjuvant or neoadjuvant chemotherapy. The median hospital stay was 2 days (range: 2-4 days). The final surgical margins and subareolar biopsy were clear in all cases. After a median follow up of 12 months (6-24 months), we observed no cases of local recurrence, or loss of implant or nipple. There was one wound complication (2.5%). None of the patients developed grade 3/4 capsular contracture, however a significant degree of rippling of the upper pole requiring autologous fat grafting was seen in 2 cases (5%). Twenty-three patients completed the questionnaire and reported a median satisfaction score of 9 out of 10 with the unclothed appearance, 10 out of 10 with the clothed appearance and 10 out of 10 with the overall body image.

Conclusions: Our study lends further support to the growing body of evidence that pre-pectoral ADM-assisted IBR following NSM is reliable and safe. It is associated with a low incidence of capsular contracture and high patient’s satisfaction. Neither prior RT nor PMRT represent contraindications to this approach.

Citation Format: Salim Tayeh, Hiba El Hage Chehade, Aisling Manson, Kefah Mokbel. The evolving role of pre-pectoral acellular dermal matrix -assisted approach in implant-based immediate breast reconstruction following conservative mastectomy: A prospective observational study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-14-07.

Abstract P4-13-05: The oncological safety of autologous fat grafting after breast conserving surgery for breast cancer: A systematic review, meta- analysis and meta regression analysis of observational studies

Background: Autologous fat grafting (AFG) has been widely adopted to correct deformities resulting from breast conserving surgery (BCS) for breast cancer. However, clinical and animal studies and in vitro experiments have revealed conflicting results regarding the oncological safety of AFG.

Aim: The aim of this study was to systematically evaluate the current literature regarding the oncological safety of AFG in patients who underwent BCS for breast cancer by performing a meta-analysis of observational studies.

Methods: A literature research was performed using the PubMed and Embase search engines from conception until May 2019 to identify all studies of patients who underwent AFG following BCS for breast cancer. Reference lists of retrieved articles and relevant previous reviews were also searched. The primary outcome was the locoregional recurrence rate. For case-control studies a standard meta-analysis was performed to calculate a pooled relative risk (RR). For case series studies, subgroup analysis and meta-regression techniques were used with historical control data to increase reliability.

Results: 26 studies reporting on 1640 BCS patients who had undergone AFG met the inclusion criteria for analysis. There were 11 case-control studies and 15 case series. For the case-controlled studies, meta-analysis using the random effects model revealed no significant difference in the locoregional recurrence rates between the AFG and control groups [RR=0.82(95% CI= 0.41-1.66)]. The mean follow up duration from surgery for the AFG group and the control group was 39 and 49 months, respectively. For the case series and historical controls, the locoregional recurrence rates were 1.85% and 2.53% respectively (p=0.33) according to subgroup and meta regression analysis. There was no strong evidence of publication bias however selection bias could not be excluded.

Conclusions: Our study suggests that AFG does not increase the risk of locoregional recurrence after BCS for breast cancer. However further prospective research is needed to confirm the oncological safety of this technique particularly in patients with high risk disease.

Citation Format: Salim Tayeh, Amtul R Carmichael, Humaa Darr, Zuhair Al-Fardan, Abdul Kasem, Moustapha Hamdi, Kefah Mokbel. The oncological safety of autologous fat grafting after breast conserving surgery for breast cancer: A systematic review, meta- analysis and meta regression analysis of observational studies [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-13-05.

Abstract P4-13-10: An evaluation of patient reported outcomes following oncoplastic breast conserving surgery with a crescent modification of the chest wall perforated flap utilizing Breast Q

Background: An increasing acceptance of chest wall perforator flaps has provided additional options for enhancing the cosmetic appearance of the conserved breast after breast cancer surgery. Traditional lateral intercostal anterior perforator (LICAP) flap involves a lateral chest wall scar. To enhance the cosmetic results of LICAP flap, we propose the crescent modification of the LICAP flap to conceal the scar in the inframammary crease.

Aim: The aim of our study was to investigate patient satisfaction and cosmetic outcome by using the BREAST-Q after undergoing crescent-modification of LICAP flap partial breast reconstruction.

Methods: All eighteen consecutive patients with who underwent crescent modification of LICAP flap reconstruction for partial breast reconstruction after wide local excision of breast cancer between June 2017 and July 2019 were invited to complete the BREAST-Q questionnaire. All patients were prospectively evaluated and their demographic, clinical and pathological details were recorded on a database.

Results: The median psychological, physical and sexual well-being scores were 93 (IQR 63-100), 82 (IQR 69-95) and 70 (IQR 46-96) respectively. The median satisfaction score with breast was 88 (IQR 66-100)

Conclusions: In a carefully selected group of women with breast cancer, our study demonstrates that the crescent-modification of the LICAP flap for partial breast reconstruction provides a safe and effective technique with preservation of satisfaction with breast, physical, psychological and sexual well-being.

Citation Format: Amtul R Carmichael, Amtul Shafee Sami, Kefah Mokbel. An evaluation of patient reported outcomes following oncoplastic breast conserving surgery with a crescent modification of the chest wall perforated flap utilizing Breast Q [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-13-10.

Abstract P2-17-02: Locoregional therapy targeted at the primary tumour improves overall survival in patients presenting with de novo stage IV metastatic breast cancer: A systematic review and meta-analysis of real-world data with 201598 patients

Background: De novo stage IV metastatic breast cancer is a complex disease that is traditionally treated using systemic therapy. There is mounting evidence that locoregional therapy (LRT), defined as resection of the primary tumour and/or localised radiotherapy, could be associated with survival improvements. We aimed to conduct a meta-analysis to inform decision making.

Methods: Using the PubMed, Cochrane and Ovid SP databases, a literature review and meta-analysis was undertaken to assess whether LRT of the primary tumour in metastatic breast cancer prolongs survival.

Results: 48 studies met the criteria for analysing the efficacy of all locoregional treatments (radiotherapy and/or surgery) and 44 studies were suitable for the analysis of surgery-only treatment of the primary. Studies were analysed for the impact of LRT on survival. All LRT resulted in a significant 32.9% reduction in mortality with LRT (N=48; HR=0.671: 95% CI 0.624-0.721). Primary resection alone resulted in a significant 36.9% mortality (N=44; HR=0.631: 95% CI 0.591-0.674).

Conclusions: This is the largest meta-analysis regarding this question to date. LRT seems to improve overall survival in stage IV disease at initial diagnosis and should be considered in selected patients after a multidisciplinary discussion.

Citation Format: Salim Tayeh, Ritika Gera, Hiba El Hage Chehade, Umar Wazir, Abdul Kasem, Kefah Mokbel. Locoregional therapy targeted at the primary tumour improves overall survival in patients presenting with de novo stage IV metastatic breast cancer: A systematic review and meta-analysis of real-world data with 201598 patients [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-17-02.

Bisphenol A: A Concise Review of Literature and a Discussion of Health and Regulatory Implications

BACKGROUND/AIM

Bisphenol A (BPA) is a ubiquitous substance found in a wide array of consumer products and healthcare consumables, and at low doses in drinking water. Currently, in the UK, it is classed as a low-risk substance with little potential for harm. It has been known to have effects on oestrogen receptors. The implications of this for public safety is currently subject to debate.

MATERIALS AND METHODS

In this study, we review recent literature regarding the effects and safety of BPA, and discuss the potential implications, in particular from the perspective of human breast oncogenesis.

RESULTS AND CONCLUSION

Recent evidence suggests that low-doses of endocrine disruptors, such as BPA, could have profound effects in breast development and cancer risk. Recent studies in murine models suggest that BPA could contribute to breast oncogenesis via several pathways. The position of regulators should shift accordingly to safeguard the public interest.

The Use of Magnetic Seeds and Radiofrequency Identifier Tags in Breast Surgery for Non-palpable Lesions

BACKGROUND

Wire-guided localisation (WGL) remains the most widely used technique to guide surgical excision of non-palpable breast lesions worldwide. However, recent technological advances have led to the advent of less invasive radiation-free localisation methods to overcome the limitations of WGL.

PATIENTS AND METHODS

This study prospectively evaluated the role of two radiation-free non-wire localisation methods. Magnetic seeds (n=16) and radiofrequency tags (n=6) were deployed under imaging guidance to guide the surgical excision in 19 consecutive patients.

RESULTS

The identification/retrieval and migration rates were 100% and 4.5%, respectively. Twenty-one out of 22 (95.5%) cases had clear surgical margins and no complications were observed. All radiologists and the surgeon rated these methods as being much better than wire localisation. Patient satisfaction data were recorded using a linear visual analogue scale (n=10/19). The mean score was 9.7/10 (range=8-10).

CONCLUSION

Our study provides further evidence that radiation-free wireless breast localisation is an effective alternative to WGL.

Is oncoplastic breast conserving surgery oncologically safe? A meta-analysis of 18,103 patients

BACKGROUND

Oncoplastic Breast Conserving Surgery (OBCS) allows adequate resection margins of tumours unsuitable for standard breast conserving surgery (SBCS) whilst allowing for better cosmesis and reduced morbidity when compared to mastectomy. However, there is limited evidence on its oncological safety.

METHODS

This study aims to compare oncological safety of OBCS with SBCS and mastectomy by examining the relative risk of cancer recurrence and re-operation rates through meta-analysis.

RESULTS

18 studies met the search criteria including 18,103 patients. The primary outcome measure (recurrence) was not significantly different between OBCS and SBCS or mastectomy (RR 0.861; 95% CI 0.640-1.160; p = 0.296). The secondary outcome measure (re-operation) initially achieved significance in favour of OBCS (RR 0.64; 95% CI 0.46-0.89; p = 0.01). However, after adjustment for publication bias this was attenuated to insignificance between the two study groups (RR 0.86; 95% CI 0.56-1.31; p = 0.44).

CONCLUSIONS

For both cancer recurrence and re-operation rate, there was no significant difference between OBCS and traditional techniques. OBCS is of comparable oncological safety to more established surgical procedures and a useful option in suitable patients.

Chemoprevention of Breast Cancer With Vitamins and Micronutrients: A Concise Review

Numerous dietary components and vitamins have been found to inhibit the molecular events and signalling pathways associated with various stages of breast cancer development. To identify the vitamins and dietary micronutrients that exert protective effects against breast cancer and define their mechanism of action, we performed a literature review of in vitro, animal and epidemiological studies and selected the in vitro and animal studies with robust molecular evidence and the epidemiological studies reporting statistically significant inverse associations for a breast cancer-specific protective effect. There is sufficient evidence from in vitro, animal and epidemiological human studies that certain vitamins, such as vitamin D3, folate, vitamin B6, and beta carotene as well as dietary micronutrients, such as curcumin, piperine, sulforaphane, indole-3-carbinol, quercetin, epigallocatechin gallate (EGCG) and omega-3 polyunsaturated fatty acids (PUFAs), display an antitumoral activity against breast cancer and have the potential to offer a natural strategy for breast cancer chemoprevention and reduce the risk of breast cancer recurrence. Therefore, a supplement that contains these micronutrients, using the safest form and dosage should be investigated in future breast cancer chemoprevention studies and as part of standard breast cancer therapy.